HumanaCommercial Clinical Policy

Zynteglo (betibeglogene autotemcel) Form

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Zynteglo (betibeglogene autotemcel)

Indications

(925259) Does the patient have an absence of contraindications for Zynteglo (betibeglogene autotemcel)? 
(925260) Is the patient diagnosed with β-thalassemia and transfusion dependent, with a confirmed non-β0/β0 or β0/β0 genotype by genetic testing? 
(925261) Has the patient received eight or more packed RBC transfusions per year in the previous 2 years, or transfused at least 100 milliliters per kg per year of packed RBCs in the previous 2 years? 
(925262) Is the patient between the ages of 4 and 50 years, and if 4 years old, weighs at least 6 kg and is clinically capable of providing the minimum number of cells for the manufacturing process? 
(925263) Is the patient a candidate for an allogeneic hematopoietic cell transplantation but ineligible due to the absence of an HLA matched donor? 

YesNoN/A
YesNoN/A
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Effective Date

12/14/2023

Last Reviewed

NA

Original Document

  Reference



Zynteglo (betibeglogene autotemcel) Medical Coverage Policy

Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0616-002
Change Summary: Updated Background, References

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

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